Welcome! Blood, guts, trauma, surgery, and life saving intervention keep us on the adrenaline roller coaster of the ER. Of course, it's not always positive. The ER can be an emotionally taxing and sometimes heartbreaking workplace, and this blog serves as an outlet for the stress of making life and death decisions each and every day.

Thursday, May 31, 2012

Cheaper does not equal better

"Patient presents for a routine spay." -- This might seem like an simple, straightforward statement, but it couldn't be more of a complicated issue.

There is no such thing as a routine spay - each and every ovariohysterectomy (the medical term for removal of the ovaries and uterus) is a complicated, in depth surgical procedure requiring vast knowledge of anatomy, surgical skills, anesthetic monitoring, and careful tissue handling. Most daytime veterinarians (at regular veterinary clinics, not emergency clinics) perform thousands of these procedures every year, making the procedure itself seem benign - but buyer beware - sometimes you get what you pay for.

Last week, a patient presented to me after experiencing an arrest under anesthesia during a spay. The patient was a previously healthy, 5 year old miniature pincher named Suzie. Suzie had been spayed at a local low cost clinic.

Before we discuss Suzie's case -- what are low cost clinics?
Low cost clinics are of several varieties; they can either be privately owned and for profit, or run by a government organization such as animal control or a humane society. Each low cost clinic is different, but in general, they attempt to serve the same purpose - providing spay and neuter surgeries at a deeply discounted price. This is with the goal of preventing the overpopulation and subsequent euthanasia of unwanted pets. In general, in order to keep overhead at a minimum, these low cost clinics do not have equivalent monitoring equipment, facilities, or staff of a fully modern hospital (of course, this depends on the specific location). In order to remain "low cost" and charge clients significantly less than the market rate of this major abdominal surgery (the spay), these facilities either have outside funding (eg., governmental grants, private donors, or trust funds), or they are forced to cut corners to save money and pass the savings on to their clients. Sometimes this means choosing the least expensive (not necessarily the best or safest) form of anesthesia, and sometimes this means that pets receive little to no anesthetic monitoring during their procedure.

Low cost clinics have an important place in our society to help control the pet population. The vast majority of these facilities are run by truly wonderful people who honestly DO care about doing the right thing for pets. The problem for me is when the client doesn't know the differences between a 'low cost' spay and a spay at their regular veterinarian - or when they believe the only difference is the dollars and cents. This isn't the case. Modern, up to date facilities provide clients with the option of pre-anesthetic blood testing, IV fluids, IV catheter (for emergency use), blood pressure monitoring, ECG, and other vital parameters. Up-to-date facilities typically have a dedicated assistant or licensed technician who has the exclusive job of monitoring patient parameters and notifying the veterinarian if anything is amiss. Even without 'fancy' equipment, just a human with training monitoring simple vitals such as heart rate, mucous membrane color, respiratory rate can go a long way in preventing tragedy. Low cost clinics typically have the pressure of performing as many procedures as possible in a day, as their profit margin is exceptionally low per case.

Back to Suzie.

Suzie was anesthetized with medications commonly used in low cost facilities, and she received appropriate dosages. She was intubated and at the time of opening her abdomen, the veterinarian noticed that her heartbeat had stopped. She was given emergency drugs (atropine and epinephrine), but as no IV catheter was placed, these were given via other less immediately effective routes. The veterinarian continued the spay, and no IV fluids were given -also due to lack of prior IV catheter placement.

Upon finishing anesthesia, Suzie suffered several seizures, likely from cerebral edema (swelling of her brain) and anoxia (lack of oxygen) during her arrest. She was transferred, comatose, to our intensive care unit, where she is making a slow, but steady improvement after receiving medications for cerebral edema. Her prognosis is uncertain, but with time, she may experience a full recovery, at the cost of several thousand dollars and days in the hospital.

How could this have been prevented?
This is a very difficult question, as the cause of the arrest was not made certain (due to lack of monitoring, trends could not be observed to determine the cause). Absolutely, an inexpensive safety measure is placing IV catheters in any patient undergoing general anesthesia; if an adverse event does occur, intravenous access is immediately available for life saving fluids and medications. Better yet, monitoring of blood pressure and depth of anesthesia can help the veterinarian and medical team to realize problems BEFORE they result in an arrest, which has a significantly improved prognosis for survival.

Please realize that complications are a part of any surgical
procedure (yes, even in human medicine!), and even with perfect
technique, monitoring and surgical skills, there is still a small
percentage of patients who will experience some problem (ranging from
very minor to very serious). The majority of patients do well during spay/neuter procedures despite the lack of cutting edge medicine. In no way do I mean to disparage low cost
facilities - they serve a very important purpose - I only wish for the client (and my readers) to have the opportunity to be educated about the differences and make an informed decision. Additionally, pet-owners should feel adequately informed about ANY medical procedure, regardless of the status of the clinic. Ask questions!

No comments:

Post a Comment

All stories contained within this blog are inspired by my life as an emergency veterinarian. Details including but not limited to name, time of visit, species, and age are changed to protect the innocent and crazy alike. Any relationship to persons or animals, living or dead, is purely coincidental.

This isn't web DVM....

These stories are shared to inspire and to entertain. They are not intended to be medical advice. If your pet is sick, the only rational thing to do is have him or her seen (in real life) by a veterinarian.

Who is that masked woman, anyway?

Ever since I was little, I always had the dream of becoming a veterinarian. The dream has been realized, and my passion is emergency medicine. ER work has many pitfalls and disadvantages, but for me, the ability to be there in a moment of crisis and help both a beloved pet and their loving family, is worth the bad days.

Reliable veterinary info on the web

Followers

Definitions and commonly seen conditions

Anemia: Low PCV (see below). Anemia can result from external hemorrhage, internal hemorrhage, destruction of blood cells in the body, or inability to make new blood cells in the bone marrow.

Azotemia: Elevation in the BUN (blood urea nitrogen) or creatinine. BUN and creatinine are body wastes typically eliminated by the kidneys; increased levels in the body indicate kidney dysfunction, obstruction of urine, or severe dehydration.

Congestive Heart Failure (CHF): Accumulation of fluid in the lungs due to failure of the heart. Some symptoms include shortness of breath, decreased appetite, rapid breathing rates, coughing, and weakness.

Feline Lower Urinary Tract disease (also called feline idiopathic cystitis): A condition resulting in frequent, painful urination, and in the most severe cases, obstruction of the urethra. FLUTD has several potential causes and is also an extreme emergency.

GDV: Gastric dilatation and volvulus. Occurs in large breed dogs; the stomach fills with gas and twists. An extreme emergency, this condition is treated with stabilization and immediate surgery.

PCV: Packed cell volume. The percentage of red blood cells contained within a given sample of whole blood. Normal for dogs and cats is typically 35%-45%.